Arthritis Tied to Higher Risk for Anxiety, Depression

Troy Brown, RN

October 05, 2018

More than one fifth (22%) of adults with arthritis have anxiety, and 12% report depression, a national survey shows. Overall, 10.3 million adults with arthritis reported symptoms of anxiety, depression, or both.

Symptoms of anxiety and depression were much more likely among younger adults, patients with chronic pain or other chronic comorbidities, and those who could not work or who had disabilities.

"The high prevalence of symptoms of anxiety and depression among adults with arthritis warrants awareness, screening, and subsequent treatment of these conditions. Health care providers can refer patients to mental health professionals and self-management education programs, and encourage physical activity to reduce anxiety and depression symptoms and improve quality of life," the authors write.

Dana Guglielmo, MPH, from the Division of Population Health Promotion, Centers for Disease Control and Prevention, and the Oak Ridge Institute for Science and Education, Tennessee, and colleagues report their findings in an article published online October 4 in Morbidity and Mortality Weekly Report.

The researchers analyzed data from 93,442 participants who completed the 2015-2017 National Health Interview Survey to estimate the national prevalence of clinically relevant symptoms of anxiety and depression among adults aged 18 years and older with arthritis.

Approximately half of the participants (n = 46,742) were randomly chosen to complete the Adult Functioning and Disability supplement during the study. Patients were considered to have arthritis if they responded "yes" to the question, "Have you ever been told by a doctor or other healthcare professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"

The survey supplement included questions about anxiety and depression symptoms. Respondents were classified as having these symptoms if their symptoms occurred daily or weekly and if the intensity of their symptoms was "a lot" or "in between a little and a lot" the last time they occurred.

"These definitions identified adults whose symptoms would likely meet Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria and also would be clinically managed, which are referred to in this report as 'clinically relevant,' although these definitions are not clinical diagnoses," the researchers explain.

Age-standardized prevalences of anxiety and depression symptoms were 22.5% (95% confidence interval [CI], 20.8 - 24.3) and 12.1% (95% CI, 10.8 - 13.4), respectively, among those with arthritis, compared with 10.7% (95% CI, 10.2 - 11.2) and 4.7% (95% CI, 4.4 - 5.0) among those without arthritis.

Symptoms were more likely among women than men; among respondents who were unemployed, unable to work, or disabled compared with adults who were employed; and among those who identified as lesbian, gay, bisexual, or "other" than among participants who identified as heterosexual.

In addition, higher symptom prevalences were seen among adults who reported chronic pain and arthritis-attributable activity limitations and increased with the number of chronic comorbidities, increasing psychological distress, and worsening self-rated health. Symptom prevalences were also higher among those who currently smoked cigarettes compared with those who had never smoked.

By contrast, symptoms were less likely among those with higher educational and income-to-poverty ratios. Symptom prevalences were lower among those who reported engaging in aerobic physical activity compared with inactive adults.

Patients with arthritis who had anxiety symptoms (44.3%; 95% CI, 40.4 - 48.3) were less likely to take medications than those with symptoms of depression (57.7%; 95% CI, 52.4 - 62.9). Just over one third (34.3%; 95% CI, 30.3 - 38.1) of patients with anxiety symptoms and 42.8% (95% CI, 37.7 - 48.1) of those with depression symptoms reported speaking with a mental health professional during the past 12 months.

Previously published research has shown an association between arthritis and poorer adherence to treatment for depression, and a survey from 2000-2001 found that almost 1 in 5 patients with arthritis and major depression said they had considered suicide during the past year.

Among patients with both arthritis and chronic pain, 31.2% reported symptoms of anxiety, and 18.7% reported symptoms of depression. The authors point to a possible link between chronic pain and anxiety or depression, which may make physical and mental health management more difficult for patients with arthritis.

Clinic-based rheumatic disease studies found that both anxiety and depression were associated with poorer response to treatment and decreased quality of life, yet only half of patients with a mental health condition receive treatment, according to the National Institute of Mental Health. "[T]he current analysis suggests that treatment prevalence among adults with arthritis might be similar or lower, especially for anxiety," the authors write.

Multifaceted Approach Needed

"Successful treatment approaches to address anxiety and depression among adults with arthritis are multifaceted and include screenings, referrals to mental health professionals, and evidence-based strategies such as regular physical activity and participation in self-management education to improve mental health," the authors explain.

Noting that mental health conditions and arthritis have been previously identified as two of the three greatest causes of work disability among adults aged 18 to 64 years, the authors say, "concerted efforts to improve arthritis and mental health outcomes could help reduce work disability."

The prevalence of anxiety and depression among adults with arthritis highlights an unmet need that clinicians can address, they continue. Patients with chronic pain conditions such as arthritis should receive integrated care, including screening for mental health problems and education on self-management.

In addition, clinicians can refer patients with arthritis to evidence-based programs such as the Chronic Disease Self-Management Program, which has demonstrated ongoing reductions in depression, fatigue, and pain, as well as increases in aerobic activity and improved self-efficacy and self-rated health.

Physical activity "can be as effective as medication or therapy for anxiety and depression," the authors write, and even patients who get less than the recommended amount of physically active can still derive physical and mental health benefits.

The authors have disclosed no relevant financial relationships.

MMWR. Published online October 4, 2018. Full text

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